In Place of Fear

An extract from the fifth chapter, In Place of Fear, of Nye Bevan’s book of essays, published in 1952, has been circulating on the internet. I’m taking the liberty of posting it here because it addresses directly (and more cogently than modern politicians seem to be able to manage) the importance of the “civilising principle” behind the National Health Service – that nobody should be denied medical assistance because they can’t afford it. As Bevan himself puts it:

Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide. But private charity and endowment, although inescapably essential at one time, cannot meet the cost of all this. If the job is to be done, the state must accept financial responsibility.

Part of this essay could have been written in 2013 rather than 1952, in response to government proposals that “foreigners” or “migrants” (or, as I prefer to call them, “people”) should be denied treatment on the NHS unless they can prove their entitlement. Bevan deals with this suggestion very well, but I think there is a point that he missed. Even if you accept that foreign visitors should be denied access to the NHS on grounds that they don’t contribute by taxation (which of course they do as soon as they buy anything that attracts VAT or earn wages in the UK), then logically you should also ban the unemployed, students, etc from access to free health care. I like to think that as a nation we wouldn’t countenance this, so why do pick out foreign visitors in this way? The answer is, of course, pure xenophobia – the lowest common denominator of British politics now as it was then..

Here is the nub of Bevan’s argument about visitors:

One of the consequences of the universality of the British Health Service is the free treatment of foreign visitors. This has given rise to a great deal of criticism, most of it ill-informed and some of it deliberately mischievous. Why should people come to Britain and enjoy the benefits of the free Health Service when they do not subscribe to the national revenues? So the argument goes. No doubt a little of this objection is still based on the confusion about contributions to which I have referred. The fact is, of course, that visitors to Britain subscribe to the national revenues as soon as they start consuming certain commodities, drink and tobacco for example, and entertainment. They make no direct contribution to the cost of the Health Service any more than does a British citizen.

However, there are a number of more potent reasons why it would be unwise as well as mean to withhold the free service from the visitor to Britain. How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? For if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody. Happily, this is one of those occasions when generosity and convenience march together. The cost of looking after the visitor who falls ill cannot amount to more than a negligible fraction of £399,000,000, the total cost of the Health Service. It is not difficult to arrive at an approximate estimate. All we have to do is look up the number of visitors to Great Britain during one year and assume they would make the same use of the Health Service as a similar number of Britishers. Divide the total cost of the Service by the population and you get the answer. I had the estimate taken out and it amounted to about £200,000 a year. Obviously this is an overestimate because people who go for holidays are not likely to need a doctor’s attention as much as others. However, there it is. for what it is worth and you will see it does not justify the fuss that has been made about it.

The whole agitation has a nasty taste. Instead of rejoicing at the opportunity to practice a civilized principle, Conservatives have tried to exploit the most disreputable emotions in this among many other attempts to discredit socialized medicine.

The numbers quoted above are very interesting. The current NHS budget for England is just a shade under £100 billion (c.f. £400 million in the 50s). The estimated current cost to the NHS of treating visitors is (possibly) as high £500 million, ie around 0.5% of the total budget. That’s a larger proportion (by about a factor 10) than in the 50s, presumably because international travel is far easier nowadays, but since migrant workers contribute a net £25 billion to the UK economy it’s hardly excessive. Indeed, the NHS itself could not function at all without the thousands of doctors and nurses who come from other countries to work in it. Neither would our university system, as a matter of fact.

It’s about time some of our politicians had the guts to stand up against the growing tide of foreigner-bashing. The one problem this country has with immigration is that there isn’t enough of it.

Anyway, my New Year message to any potential visitors to these shores, whether they be Bulgarians or Romanians or any other citizens of this planet, is a great big Welcome. And if you get ill while you’re here we’ll look after you. Because we’re like that. At least, I hope we are.

21 Responses to “In Place of Fear”

  1. Anton Garrett Says:

    Two problems have arisen with the cost of the NHS since Bevan’s day: (1) medicine has made huge advances so that a lot more can be done, so that it costs a lot more per capita than in 1950; (2) there are FOUR times as many administrators per (doctor + nurse) in public than in private medicine.

    Re (2), I have no sympathy, and even how it got like that is a diversion. Give 2/3 of administrator’s a year’s notice (let’s be generous here) and warn hospitals that they have a year to reorganise their own admin.

    Re (1), there needs to be a national debate on what should be totally free (as emergency treatment should be, for anybody in the land and regardless of nationality) and what treatments might be suitable for a part-taxpayer-funded, part insurance-funded scheme.

    Immigration is a separate issue. Its purpose is to raise tax revenue and help to support the ageing baby boom generation. However if you let too many people in who do not wish to join in the indigenous vision of what society should be then there is a risk of unauthorised change to that vision. Cultural identity is something that runs very deep – certainly deeper than economic factors. Again, I simply hope that there will be a debate without the usual knee-jerk calls of Racist or Damn’ Foreigner, and that politicians will heed that debate.

    • telescoper Says:

      Cultural identity does indeed run deep. Ours is the product of wave after wave of immigration that has formed a society that celebrates diversity and personal freedom. It hasn’t always been like that. We have endured centuries of religious intolerance and widespread oppression of the poor before getting to where we are now. We’ve got there, at least in part, because we’re a nation of mongrels.

      What our society will be like in 100 years time is anyone’s guess, but although it is bound to change with time, I hope and believe that a democracy founded on individual liberty and the rule of law will remain.

      • Anton Garrett Says:

        I agree with your analysis of the past and of how our identity was formed. But previous waves of immigration comprised people who wished to assimilate, whereas policy here for the last 30 years has been something called Multiculturalism which believes it is right (as I do) for the Sikhs to have a cultural identity in Punjab, for the Hindus to have a cultural identity in India (etc) but not right for the English to have a cultural identity in England, which must instead be the locus of an experiment for everybody else. That is itself a form of racism. I would also be interested in the figures for the rate of inward immigration relative to the established population in recent and ancient times, as change that is too rapid is asking for trouble.

        Another concern is that people are coming here looking for jobs when we have millions of unemployed. An analysis of that needs to be done and a remedy put in place.

      • telescoper Says:

        I can’t agree with your first point. We have never required Jewish immigrants to surrender their cultural identity, nor should we with muslims or Sikhs or atheists. The comparison of “English” with “Sikh” seems to imply that to be English is to be Christian, which I would contest. What matters is that immigrants agree to be bound by the laws of the land, which can only be changed by democratic consent, and to respect the values enshrined within them. This would all be a lot simpler if we became a fully secular state so that all matters of religion were treated equally. Sadly, we’re very far from that.

      • Anton Garrett Says:

        I too am against political Christianity (as I regularly try to explain to various Christian friends). But cultural identity is based on shared beliefs in general, and religion is just a subset of belief systems. Secularism is a belief system that rests on axioms too. Also, some religions are intrinsically political and should be understood to be such.

      • “But previous waves of immigration comprised people who wished to assimilate”

        Or people who wished to, and did, conquer. 🙂

      • Anton Garrett Says:

        Phillip: The Normans and the Danes came with the intent of immediate violent pillage, which is not the subject here.

        Peter: We actually required Jewish immigrants NOT to give up their Jewish identity for many centuries, as they were discriminated against by law.

      • “What matters is that immigrants agree to be bound by the laws of the land, which can only be changed by democratic consent, and to respect the values enshrined within them.”

        I agree. The problem is that if immigration happens too fast, then it is easy for immigrants to live in a parallel society, where they want the benefits of their new homeland but aren’t willing to be bound by the laws of the land or, if they have the majority, change them. Not all immigrants are political refugees, and even those that are don’t necessarily espouse the views of their new country of residence.

        Some will see it as paradox, but it is those of us who value a free and liberal society who should keep our eyes open. In how many countries is homosexuality illegal? In some it carries the death penalty.

        Apparently there are already parts of England where immigrants enforce sharia law in their neighbourhood. (Of course this applies to everyone there, as indeed do all laws, correctly in my mind.) That they are not allowed to do this is not the point; the point is that too little is done to combat it.

      • “The Normans and the Danes came with the intent of immediate violent pillage, which is not the subject here.”

        Note the smiley.

        Yes, true, but so did the Angles and Saxons.

      • Anton Garrett Says:

        PS In no way was I implying that English identity should be defined religiously. It should be defined in any way that the English choose. What I am insisting is that such an identity does exist and should be acknowledged, whereas multiculturalists in England insist that the place should be used as an experiment for every other culture to mix. That is anomalous because it grants cultural identities to everybody *except* the English. I’m doing my best to say neither more nor less than I mean in an area of debate which is contentious.

    • “Immigration is a separate issue. Its purpose is to raise tax revenue and help to support the ageing baby boom generation.”

      There are many reasons for immigration. What you refer to is one reason some governments encourage some forms of immigration. I think that this is misguided. First, obviously more people paying taxes means more revenue, but this is balanced by higher costs. It’s not the case that countries with large populations are generally better off. (The standard of living in Luxembourg is higher than in India.) Second, if the birth rate is too low, then the government should take steps to change this, just as they should if it is too high. Immigration won’t solve the problem. If immigrants become well integrated, then they will have as few children as the natives, so one has just delayed the problem and made it bigger for the next generation to deal with. If they don’t, then we have the problems created by parallel societies. Also, encouraging immigration by young, well qualified people is not in the interests of their home country. It is rather egotistical to expect a country to pay for the good education of people and then siphon off the best ones.

      Again, there are several reasons for immigration. My wife and I are both immigrants. There is a real problem, though, when anyone discussing any problems whatsoever with respect to immigration is immediately labelled xenophobic.

    • Have you got a source for your 4 times as many administrators as doctors and nurses in the NHS compared to the private sector? Or is it just one of those so called facts that opponents of the NHS like to bandy around?

      • Anton Garrett Says:

        Yes, certainly, although I was working from memory above and my figures were for the administrator-to-nurse ratio, not the administrator-to-(doctor + nurse) ratio; my apologies. It was a survey performed by a consultant oncologist at Barts, Maurice Slevin. He found 269080 managers, administrators ans support staff and 266170 nurses, all quoted as “full time equivalent” figures. He then subtracted from the former figure all who operate ambulances and do maintenance work, and even doctors’ secretaries. In a private hospital, in contrast, he found 43 managers and 240 nurses. Even after his subtraction there were more than 4 times as many administrators per nurse in the NHS. Moreover his survey was performed in 2001 and in the six years prior to that the number of nurses had increased by 7.8% whereas the number of administrators had increased by 48%. Given the itch of NuLabour to get as many people as it could onto the State payroll I expect that the ratio probably worsened subsequently. I took these figures from a book called The Welfare State We’re In by James Bartholomew, ch.3, but I’ve confirmed that you can find further details online by googling.

        Moreover in 1964 a total of 48016 people in the NHS were described as “administrative and clerical”, a figure which rose over the next 10 years to 79114; this rise took place at a much faster rate than for any other category of employee. (From a written parliamentary answer, quoted in “Restructuring the Health Service” by Tom Heller, 1978.)

      • telescoper Says:

        It would be interesting to know how the number of managers in the university system has changed over a similar period..

    • So you’ve quoted figures from the much derided “The Welfare State We’re In.”

      The first publication of the book was slammed for selective quoting of stats and in the later updated edition the author failed to recognise improved outcomes in the NHS. For example the London School of Hygiene and Tropical Medicine reported in 2011 that overall cancer survival times in England and Wales improved from one year for those diagnosed in 1971-2 to 5.8 years for patients diagnosed in 2007. But the updated version of the book chose to omit this.

      The comparison of administrators to nurses in the public and private sectors is fallacious because:
      a) NHS hospitals have other requirements upon them that private hospitals do not, such as healthcare promotion
      b) it’s not clear what NHS posts were excluded in the comparison
      c) you are only comparing hospitals when you should be comparing whole healthcare systems and outcomes
      d) private sector hospitals nearly wholly depend upon patients who are paid for by private medical insurance and the costs of the administrators for the insurance company are not included in the private sector comparison.

      Indeed on the final two points it is interesting to note that the US has the highest per capita costs for health in the developed world, but does not have the best outcomes. It operates a mainly privately run healthcare system. The US spends more per capita; has few doctors per capita than the UK and other countries; and perhaps most importantly the US does not have noticeably better outcomes than other developed nations, indeed life expectancy is lower than many developed nations.

      For some resources go to:

      http://www.commonwealthfund.org/Publications/In-the-Literature/2013/Nov/Access-Affordability-and-Insurance.aspx

      http://finance.yahoo.com/news/america-health-system-stacks-against-091500353.html

      The NHS isn’t perfect, but I very much prefer it to a private insurance based system. I would rather have the UK system than the US system.

      • Anton Garrett Says:

        So would I. But that is not what we were discussing, is it? The point is the excess of administrators in the NHS. I would be happy to see the money presently spent on their salaries redeployed on kit and medics and nurses. You can find the same stats from Slevin online without the taint that you consider Bartholomew provides. It is perfectly obvious from Slevin’s stats – bear in mind that doctors’ secretaries were *excluded* – that the majority of NHS administrators are superfluous and should therefore be given notice. This cannot be done by evolution of admin; revolution is needed. I’d bring in a few senior administrators from private hospitals to show how it is done. The problem is systemic, not personal; I’m sure that the majority of administrators work conscientiously. But that too is not the point.

  2. “Are British citizens to carry means of identification everywhere to prove that they are not visitors?”

    This comment shows a difference between the UK and most other countries (at least in Europe), where ID cards are mandatory. Are there still no mandatory ID cards in the UK?

    Even if the total cost is negligible, I can understand the objections of people who voluntarily live in a society with relatively high taxes and good public services have against people who intentionally travel to such a country, from a neoliberal country with low taxes and expensive private health insurance, explicitly in order to have access to health care. Yes, it could be that such travellers are themselves in favour of a better society, maybe they didn’t travel in order to gain access to health care etc, so it would be wrong to complain against all visitors who have access to health care. On the other hand, if the system is intentionally abused, this should be combated—not only but also in the interest of keeping it viable. After all, if someone steals something from a shop, we don’t say “Don’t worry, it’s a small fraction of the GNP” and let it go at that. If such theft is not prosecuted and people come to such shops since they know that they can steal, then something needs to be done. I am not saying that this is a big problem. Rather, I am saying that I can understand the objections to some extent. I also don’t think that everyone who objects does so for reasons of xenophobia. The same problem would occur if health care in England were organized at the county level and one county had tax-paid health care, and higher taxes, and the neighbouring county had expensive private insurance and low taxes. It just so happens that that’s not the case, and those (few though they may be) in question are necessarily foreigners. After all, if I say I don’t like Maggie Thatcher, that doesn’t make me a misogynist.

    I think the tax-paid health-care system in England is the best solution, at least in isolation. In most European countries, there is mandatory health insurance, and it costs the same for everyone or costs more if one earns more (like with taxes) but the cost does not depend on one’s state of health. When requesting health care in another country, proof of coverage elsewhere is required, but this is not a problem since everyone has it. All the countries agree to treat patients from other countries, and perhaps there is some sort of financial compensation behind the scenes. (I have experienced this twice, once when my son fell down a mountain in Sweden and once when my wife had a premature birth in Spain. In both cases, they just noted the number on the card and that was that.) In England, obviously, this doesn’t work, because there is no health-care ID. (When UK citizens need health care elsewhere in Europe, they need to show their passport.)

    In general, many things within the EU do not work as well as they could because some things are based on citizenship, some on place of residence, some on place of work etc. The easier it is to travel, the more abuse is possible. It is probably the case that rich tax exiles cost the country more, and more should be done about that, but this doesn’t mean that smaller problems should be ignored. In the long term, if some countries decide that they want high taxes and good public services, then problems can occur. If people move from one country to another and otherwise behave like the locals, fine, but if people keep their main residence in one country and access public services in another, then something is wrong. There are two solutions: EU-wide tax and public-service policies, or more restrictions on movement. If anyone has a third solution, let me know. If only those political parties who actually are xenophobic address this issue, then they might gain support from people who otherwise wouldn’t support them. This is already happening in some countries which are traditionally liberal (in the good sense, not in the economic sense) with high taxes and good public services where right-wing xenophobic parties are gaining support. As long as the left treats all of their supporters as xenophobic, when the supporters themselves know that they are not, then the chance of a sensible solution is quite reduced.

  3. This is succinct and well worth the time it took to read. Excellent points made. Would you mind if I reproduce it in January’s issue of http://www.caretosharemagazine.wordpress.com ? You’d get proper credit of course.

    Please let me know either way.

    Cheers,

    Stuart

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